The Tight Gastrocnemius: Is it the Root of Most Foot Pain?

The Tight Gastrocnemius – Is it the Root of Most Foot pathology?

By: Michael Zapf, DPM, MPH, FACFAS

 

If you were referred to this article after your office visit it was because you, or your child, have a condition that is contributing to or even causing a lot of your foot symptoms. The condition is called Gastrocnemius Equinus (GE). I admit that it is a tough concept to understand, but I am going to give it a shot.Despite looking good, high heels shorten your gastrocnemius, which can eventually lead to pain.

The gastrocnemius muscle is a big calf muscle. Doing heel raise exercises, where you stand on the ball of your foot, makes the muscle bigger and stronger and gives the leg a shape many people find attractive. The top of the muscle is attached to your thighbone, the femur, and the bottom of the muscle forms part of the Achilles tendon which attaches on the bone at the back of your foot called the calcaneus.  An interesting anatomical fact is that the Achilles tendon is composed of two muscles: the soleus, which is found only deep and behind the calf muscle and is almost never a problem, and the more superficial and bigger gastrocnemius muscle which is frequently a cause of pain and symptoms.

When you walk this muscle contracts and lifts your heel off the ground which propels you forward. In many people the gastrocnemius muscle is short or tight which leads to problems like flat feet, bunions, metatarsalgia, capsulitis, curled fifth toes, hammertoe’s, sesamoiditis, plantar fasciitis and Achilles tendon inflammation, tendinitis, and even Achilles tendon rupture.

How we can measure the tightness of the gastrocWe test for tightness of this muscle by measuring the amount of motion at the ankle joint with the knee flexed and extended. I will try to avoid the mechanics of this test which only tends to confuse people but adequate ankle joint up motion, or dorsiflexion, with the knee flexed or bent, and a lack of ankle joint up motion (dorsiflexion) with the knee straight is called the Silfverskiold test. A lack of ankle joint dorsiflexion is a positive test meaning that the patients have a distinct lack of up motion (dorsiflexion ) due to a very tight gastrocnemius portion of the Achilles tendon. According to an article in the May 2011 Podiatry Today by Stephen L. Barrett, DPM the tight gastrocnemius muscle accounts for the overwhelming majority of foot problems and is largely ignored during examination and treatment.

Very tight Achilles tendons are also quite common. One study showed that 88% of patients with forefoot and midfoot pain and pathology had gastrocnemius equinus. It is so common that we almost assume everybody has it and we tend to ignore its role and importance in foot pathology.

How to stretch out your gastroc muscleSo, how do you treat GE? The most common therapy is a stretching routine. This stretch involves standing on the ground facing a wall. With 1 foot you take a step halfway to the wall. Keep the knee of the foot in the back straight and the heel on the ground and leaned forward. You need to hold the stretch for 20 seconds without bouncing. Then repeat the exercise with the other foot. A proper stretch would involve each foot being stretched for 20 seconds three times. This is the most simple two-minute stretch available for GE and should be done with everybody who has a tight Achilles tendon before every athletic encounter. This will warm up the calf muscle and tendon so that it will not be hurt during physical activities.

A better method to stretch the type gastrocnemius muscle is using a night splint. With a night splint the Achilles tendon and gastrocnemius muscle is stretched for 3 to 8 hours at a time. This is an aggressive way to stretch the Achilles tendon and the gastrocnemius muscle. Even this aggressive stretch is not very effective, however, one study showed that only 2°-3° ofA night splint designed to stretch out the gastroc muscle improvement were made after using a night splint for an entire year. The photograph to the right shows a night splint attached in the foot. Honestly, it is not as uncomfortable as it looks. In truth, however, the main advantage to a night splint for a tight Achilles tendon is the ability to say we tried something conservative before recommending or suggesting a surgery.

Since the Achilles tendon is tight a traditional conservative treatment has been using a heel lift. This will allow the foot to function with a tight gastrocnemius muscle and Achilles tendon. This can be done by wearing shoes that have a heel or by inserting heel lifts under the heel inside the shoe. Because the tight gastrocnemius tendon produces so much pain and pathology relaxing the tendon with an elevated heel often produces surprising pain relief. This is why women in higher heeled shoes and man in a cowboy boot often state that their feet feel more comfortable with the heel elevation. Raising the heel has some drawbacks, however. Raising the heel encourages bunions, hammertoe’s, sesamoiditis and pain and swelling under the ball of the foot. Pain in the front and the ball of the foot is why women, and men, tend to wear lower heeled shoes as they progress through life.

For those people who have pathologically tight Achilles tendon and stretching and heel lifts have not provided enough relief of pain, there are surgeries designed to lengthen the tendon. This is not as radical as it sounds. As I stated above, a tight Achilles tendon is at the root of most foot problems. Unfortunately, addressing the tight Achilles tendon with Achilles tendon lengthening is the singular most neglected surgical procedure on the foot and leg. Even in our office we are guilty of lengthening this tendon in only the most severe cases. Lengthening the tendon necessarily weakens the muscle by a few percentage points. It requires a period of physical therapy and rehabilitation. Because of this difficulty we often ignore the problem and the surgery.

The traditional Achilles tendon lengthening involves a surgery with an incision on the back of the leg and performing a technique that lengthens the tendon. Recently, Dr. Darren Payne introduced us to the concept of an endoscopic Achilles tendon lengthening. This procedure requires only a half-inch incision and can be done under just a little sedation.

One place where we tend to truly pay attention to the type Achilles tendon and the gastrocnemius muscle is with children. Children with painful flat feet almost invariably have the complication of a tight gastrocnemius muscle. We will always start with orthotics, stretching, a night splint and heel lifts but, sometimes, this is not enough. If a surgical approach is ever contemplated, it will always involve lengthening a tight gastrocnemius muscle. Fortunately, children have a much greater ability then we adults to bounce back from this surgery.

In conclusion, a tight Achilles tendon, especially the gastrocnemius portion, is one of the major causes of foot pathology and pain. Unfortunately, it is usually and frequently ignored. It is the chief cause of painful flat feet in children and adults. Nearly every adult with a painful collapsing flat foot, and there are many in the senior years, has the flat foot because of a tight gastrocnemius muscle. This muscle is that important. Heel lifts and stretching can help. Stretching the physical therapy helps even more. When conservative measures do not help we need to think more often about the benefits of Achilles tendon lengthening surgery.

If you have any questions about this topic, or would like an exam by one of our doctors, please feel free to contact us via our contact page here, or give us a call anytime!

Do I Really Need Sunscreen on my Feet?

Do I Really Need Sunscreen on my Feet?

by: Dr. Stephen Benson, DPM, FACFAS

 

Most Americans have recently become much more aware of the risk of skin cancer in their everyday lives, and have increased their use of sunscreen as a result.  Feet, however, often get overlooked despite this development.  People don’t often realize that skin cancer can occur on the feet from unprotected sun exposure, and they do not bother applying sunscreen.  It is important to remember that skin cancer of the foot is prevalent and can be fatal if not caught early.  While all types of skin cancer, including basal cell and squamous cell carcinoma, can be found on the foot, the most common is also the most serious form, melanoma.  Melanoma symptoms can be as subtle as an abnormal looking mole or freckle, and these can occur anywhere on the foot, including in between the toes and even under the toenail.  These often go unnoticed without routine foot exams.

Early diagnosis is the key to effective treatment for any skin cancer.  Many people, however, are not looking for the early stage warning signs, or taking the same precautions they do to prevent melanoma for other areas of their body.  Unfortunately, often times, skin cancer in this region is not diagnosed until the later stages.  I have seen cases where skin cancer on the foot has progressed to severe stages, and it was caught in a routine exam, not even a result of the patient noticing an abnormality.  Often times the surgery required to remove the cancer becomes more difficult as time goes on, due to the progression and potential spreading of the illness.  There have been patients in my care where all I needed to do was remove the “bad” skin and they were fine, but there have also been cases where the patient needed to have a part of their toe, their whole foot, or in the most extreme cases their leg removed in order to fully treat the cancer.

Put Sunscreen on Your Feet to Help Prevent CancerI advise my patients to regularly inspect their feet, including the soles, in between toes, and even under the toenails for any changing moles or spots.  It is important to have any suspicious areas promptly examined by a foot and ankle specialist, as they can confirm it being suspect, and have it biopsied for signs of malignancy.  This is easily done as an in office procedure at our practice, or other practices.  While this article might seem a bit grim, there are simple measures that everyone can take to prevent any of this happening, and provided you put in the little bit of extra effort you will be just fine.  Please remember to apply suncreen whenever your feet will be exposed to the sun for a prolonged period of time.  This not only includes the beach and pool, but also when outdoors for any reason with open sandals or flip-flops.

If you would like a foot exam to determine if a mole or spot is suspect, please feel free to make an appointment at either of our offices to come in and see one of our doctors.  Our contact information is here, Contact Page.

Stephen Benson, DPM, FACFAS

Sever’s Disease in Children

Sever’s Disease in Children

By: Michael Zapf, DPM

Richard and Rachel are twins who share a lot in life, including Sever’s disease. Before I go any further, I want to say that this condition is one of the most poorly named in all of medicine. It’s a condition of young athletes that lasts for a year or two and never has any serious consequences. It does not deserve the name “disease”. In my office I always refer to it as Sever’s condition and never use the “D” word. For the rest of this article I will refer it as Sever’s or Sever’s condition.

Now, let’s get back to our twins. They are 11 years old and play a variety of sports. Rachel does soccer, softball and dance while Richard’s favorites are soccer, lacrosse and tennis. They both presented to my office this year, Rachel in January and Richard just last week with pain in the back and bottom of their heels. The pain is aggravated by activities and gets so painful that they noticeably limp.

Sever's DiseaseThe condition affects both boys and girls during early adolescence. The age range is typically 7-15 years old for boys and 5-13 years old for girls. It is no coincidence that this is the age where the growth plates close. Severs condition is related to the growth plate- like structure on the back of the heel called the apophysis. In the picture that accompanies this description, the apophysis is the rather white crescent-shaped bone just below the arrow. The arrow, itself, is pointing at the union of the apophysis with the main part of the heel bone. At this point they look like separate bones but they are not. The black band, where the arrow is pointing, will soon fill in with bone and the problem will be over. Until then, the pain can be excruciating.

Two factors that always seem to accompany Severs condition are tight Achilles tendons and aggressive athletic activities. The third component that sometimes plays role is pronation or flattening of the foot.

When I entered podiatric medical school there were still some textbooks that said that Sever’s condition is mostly aSever's Diagram problem of boys. That is clearly no longer true. Now that the girls are equally active in sports they are equally eligible to develop Sever’s condition. Since activity level plays a role in the level of pain these children have, so does reducing activities play a role in lessening the pain. Parents, coaches and physical education teachers need to be aware that they may have to reduce the heavy athletic schedule of these student athletes to get a handle on the pain. There is no way, just by looking, that parents and coaches can tell when the heel is hurting – we have to take the word of the child/patient.

The Achilles tendon attaches to the apophysis, which is the area of the bone below the arrow. If the Achilles tendon is very tight, and it almost always is in patients with Sever’s, it can cause a rapid ballistic pull on the apophysis increasing the pain. In the office we will test for a tight Achilles tendon. If it is tight we will usually recommend relaxing the pull of the tendon by wearing shoes with a heel or placing a heel lift in athletic shoes and cleats. Heel stretching exercises can also be beneficial but it is usually very difficult to get these young athletes to do it as aggressively and as frequently as it needs to be done. Sometimes we resort to a splint that stretches the Achilles tendon for several hours at a time.

Sometimes pronation, or flattening of the feet, has a significant role in the creation and prolongation of the pain of Severs condition. When it does, we can often decrease the level of pain with either over-the-counter or custom shoe inserts called orthotics. We can test for the ability of functional orthotics to reduce the pain by placing tape on the foot in a particular way to take this stretch off of the plantar fascia. Simply put, if the tape strapping makes the child less painful, so will an orthotic.

The application of ice to the heel is always a helpful aid in treating Sever’s condition. This can be done in a variety of ways but we recommend that it be done after athletic activities, before bed and any time that the child is complaining of heel pain.

The use of a non-steroidal medicine like aspirin and Motrin is controversial. I agree that it can be useful to decrease the pain and inflammation of Sever’s after athletic activities, but I oppose using these medications to allow the student athlete to play athletics more aggressively.

About twice a year we see a patient who has Sever’s pain so severe that the steps above do not provide enough relief. These children are in so much pain that they, sometimes, are not even able to walk to class. These cases usually require a fiberglass cast be placed on the leg and foot. The cast decreases activity so much that healing can now outpace injury. The cast is only needed for two or three weeks but sometimes it is the difference between the agony and the feet.

The good news for Richard and Rachel is that, no matter what they do, they will get older and more mature and the apophysis will close, eliminating their pain.

Treatment wise, Richard responded to the initial steps of decreasing some of his more aggressive back to activities, the use of heel lifts, regular stretching and ice therapy. Rachel still had pain with these measures but received significant relieved when we added functional orthotics to her regimen. Both have continued to be very active and should be completely out of pain in about a year and, certainly, by the time they reach high school.

A Patient’s Guide to Heel Pain

A Patient’s Guide to Heel Pain …

What You Need To Know

By:

Michael Zapf, D.P.M.

Diplomate, American Board of Podiatric Surgery

Diplomate, American Board of Podiatric Orthopedics

Fellow, American College of Foot and Ankle Surgery

Fellow, American College of Foot and Ankle Orthopedics

Selected Best Podiatrist by Two Daily News Readers’ Poll

Former Assistant Professor, CA College of Podiatric Medicine

Past Assistant Clinical Faculty, L.A. County / U.S.C. Medical Center

Revised 6-1-2011

 

What are the symptoms of heel pain?

The typical symptoms of heel pain are pain on the inside of the heel when you stand or walk after periods of rest or inactivity; especially pain with the first step in the morning. The pain lessens after walking for a while. Typically in the afternoon the heel hurts whether you rest or walk on it. The pain can vary from mild to debilitating and can last from a few weeks to many years. The pain can be centered just under the heel or it can extend across the arch of the foot. The pain can appear to be cured, at times, only to return months or years later. You may have noted that shoes with a bit of an elevated heel or walking with your feet turned inward helps to relieve the pain. Plantar fasciitis is uncommon, but not unheard of, in anyone younger than 30.

What is going on here?

The Plantar FasciaTo understand heel pain you first need a quick lesson in anatomy. There is a thick band or belt of tissue that extends from your toes to your heel and is just under the skin. The band is called the plantar fascia or PF. At the front of the foot it attaches to all five toes and at back it attaches to the heel bone, the calcaneus, with a 1 inch wide attachment. The purpose of the plantar fascia is to provide stability to the foot when you lift your heel for walking, running and climbing. It is possible to do more of these activities then your plantar fascia can handle in any given time period in pain results. So the first and simplest cause of heel pain is overuse were the plantar fascia hurts at its weakest point, the attachment site on the heel bone. We can easily see this visually in the office with the diagnostic ultrasound machine which allows us to measure the thickness of the plantar fascia at the heel attachment site. A normal plantar fascia is 3-4 mm thick and the thickness of a painful plantar fascia is typically six or more millimeters thick.

If the overuse and over-pull of the plantar fascia goes on for a long period of time, some say 18 months or more, a spur can develop on the heel bone which you can visualize with an x-ray. Most authorities believe that the heel spur is not the cause of heel pain. People can have a huge heel spur with no pain while others can have tremendous pain without a heel spur. I believe that the heel spur is a marker to indicate that the process has been going on for almost 2 years or more. These people will probably require more treatment than just a cortisone injection.

Fasciitis vs. Fasciosis

The terms fasciitis and fasciosis look suspiciously similar but they refer to very different things. The “-itis” ending of fasciitis gives a clue to its meaning: inflammation. During the early stages of this condition where the over-pull or overuse of the plantar fascia is in its beginning stages the condition is inflammatory. Anti-inflammatory pills and cortisone injections are very useful in this stage. As time passes the condition morphs into a chronic pain phase where we refer to it as fasciosis. Anti-inflammatory pills and cortisone injections are not effective during the fasciosis phase. If you have had a cortisone injection for your “plantar fasciitis” that only lasted for a few days you are probably in the “fasciosis” stage.

What causes the spur?

Heel SpurThe cause of the spur has been an intriguing question that does not have a clear answer. The best explanation I have heard is that the spur forms as a reaction to an accumulation of micro-fractures to the heel bone. These micro fractures, like all fractures, heal by having the tissue covering the bone, the periosteum, produce more bone which will, in effect, glue the bones together. With chronic plantar fasciitis, or fasciosis, there are tens of thousands or hundreds of thousands of little fascial tugs on the heel bone that produce tens of thousands or hundreds of thousands of microscopic heel bone fractures. The extra bone produced to heal the microscopic heel bone fractures is visualized as the spur. Although it may feel like it, the spur does not point downward towards the ground

When do you suspect that there might be a stress fracture?

Long standing over-pull and overuse of the plantar fascia can also lead to a stress fracture of the heel bone. This is not common but it can occur. I am suspicious of a stress fracture if squeezing the heel bone between the palms of my hand produces pain on the affected side but not the unaffected side. Regular x-rays taken in the office can give a clue that you might have a stress fracture. Confirmatory tests for a stress fracture often need a bone scan or an MRI both of which are done at a radiology center.

Bone scans are very useful tools. A radioactive dye is injected in the arm and an x-ray scan is taken of the heel bone three hours later. A “hot” scan which shows a lot of activity in the heel bone is diagnostic for a stress fracture. An example of a “hot” scan is attached the right heel has a very hot spot indicating that something is going wrong. It could either be cancer, an infection or a heel stress fracture, depending on the symptoms of the patient. In this case, it was a heel stress fracture.Bone Scan

As useful as bone scans are, they are  being replaced with MRIs as the cost of the MRIs have decreased. MRIs can also get useful information about the plantar fascia and the surrounding tendons that you cannot get with a bone scan. I cannot remember the last time I ordered a bone scan to evaluate the possibility of a stress fracture in the heel. If the MRI shows you have a stress fracture expect to be in a walking cast for 3-6 weeks to allow the foot to heal.

Quick summary so far

1)      Plantar fasciitis produces pain with the first step after resting

2)      The most common cause of pain is inflammation of the fascia at the heel insertion

3)      Long standing plantar fasciitis leads to a non-inflammatory chronic pain we call plantar fasciosis

4)      Untreated plantar fasciitis/fasciosis can lead to a stress fracture of the heel

5)      The heel spur that forms is not the cause of pain but is a marker that the process has been going on for 18 months or more

Factors that Contribute to Plantar Fasciitis/Fasciosis/Stress Fracture

Here is a non-exhaustive list of the factors that can lead to plantar fasciitis which leads to plantar fasciosis and calcaneal stress fractures:

  1. activity level
  2. weight
  3. pronation or flattening of the foot
  4. floor surface
  5. shoe type
  6. foot type and ligamentous laxity

 

What is pronation and what does it have to do with my foot pain?

Our feet are the product of a Master Designer. They have to do two very opposite things every walking step we take. First the foot hits the ground and pronates. In pronation the foot collapses and becomes very flexible. This flexibility allows the foot to adapt to changes in terrain. As the opposite foot swings by the planted foot the foot begins to supinate into a foot rigid enough to support push-off. A supinated foot is very stable and not prone to plantar fasciitis. A pronated foot elongates and allows for a potentially painful stretch of the plantar fascia. Some pronation and supination is normal in every walking step. Pronation beyond the normal amount is one of the most common causes of over-stretching of the plantar fascia and, thus, pronation.

What role does my weight have on heel pain? Pregnancy?

Any force causing the foot to elongate, or flatten, can contribute to the pain of plantar fasciitis. This includes weight, which is implicated in as many as 70% of the cases of heel pain. Excess weight also seems to be the one common thread connecting those few people who end up having heel pain surgery. While difficult or impossible for many people to achieve, weight loss can help their foot pain considerably.

Plantar fasciitis is common in pregnancy because of weight gain and the presence of the hormone Relaxin. Relaxin is produced in the latter stages of pregnancy to allow the pelvic ligaments to stretch. There is a ligament in the foot that also responds to this hormone and causes the foot to stretch putting strain on the plantar fascia. Usually pregnancy related plantar fasciitis goes away after birth, but not always.

Activity Level

Being an overuse injury, plantar fasciitis is aggravated by increased activity that causes the plantar fascia to repeatedly pull on the heel bone. The worst activity I can think of to aggravate a plantar fascia is one where the foot is repeatedly struck on the ground with a great ballistic force – running on an inclined treadmill. The best activity I can think of would be swimming. Here is a list of activities in decreasing order of their impact on plantar fasciitis:

Running on an inclined treadmill

Running on a flat treadmill

Stairmaster

Walking

Elliptical machine

Health writer

Rowing machine

Swimming

 

There may come a time when you need to increase your activity levels to master your plantar fasciitis but I do not like to start there. I refer to keep you performing your favorite athletic and fitness endeavors if at all possible. Certainly, if you have a stress fracture and need to wear a walking cast, something has to give.

 

Floor Surface

This may at first seem like an unlikely candidate for modification by hard floor surfaces are certainly worse on the feet been something softer. Running on a track, for instance, is easier on your heels and running on the blacktop which, in turn, is easier than running on concrete sidewalks. At home if you spend a lot of time standing at a workbench or a kitchen counter you might want to add a soft floor mat for that purpose. Similarly, a cashier may also want to add a soft floor mat or, if possible, a stool on which to sit.

 

Shoe Type – Elevate That Heel

It is a simple anatomical fact that the plantar fascia relaxes as the heel is raised. We can use this fact to modify the stresses of daily activity by, if it is possible, raising the heel height of the shoes you wear. For women, it is easy to find work shoes, dress shoes and casual shoes with a bit of a heel. Doing this for men is more difficult unless you’re fond of Western boots. Conversely, walking in bare feet, socks only or shoes with no heel at all can aggravate pain of plantar fasciitis. If you need to wear shoes without a bit of a heel, consider purchasing and using some heel lifts that fit in the shoes under your heels. Sorbothane is a good brand of heel lift, if you can find them. Look for them at sporting goods stores. A warning here, heel cups are not the same thing as a heel lift. Heel cups are usually not thick enough to act as heel elevators. They may be helpful for attenuating the impact force of the heel on the ground but they are not very effective at raising the heel.

 

Foot Type and Ligament Flexibility

People who have flat feet put a lot more stress on their plantar fascia that people with a high arched foot and consequently have more plantar fasciitis. Nominally there is nothing you can do about her foot flatness type or your foot ligament flexibility. A flexible flat foot, however, usually responds very well to functional orthotics, a topic which we will discuss later.

 

Self-help for Plantar Fasciitis

There were several things you can do on your own before seeking professional help. Start by wearing well-made shoes that have a bit of a heel. Try making your floor surface a little softer. Over-the-counter arch supports may help, a good brand here is Superfeet which can be found at most athletic shoe stores and sporting goods stores. Stretch your foot ligaments before you exercise or work and apply an ice pack to your heel when hurts and after activities. In the morning for you get out of bed beside her heel on a tennis ball or a bottle.

 

Who should you go to for your heel pain?

It is probably no surprise that I think that heel pain patients should see a podiatrist. Podiatrists know the biomechanics of heel pain and how to treat it with taping and orthotics. We have the medical ability to take and interpret x-rays and diagnostic ultrasound and to administer oral anti-inflammatory medication and cortisone injections. We have the surgical ability to treat the plantar fascia with noninvasive means like shockwave therapy, minimally invasive procedures like radiofrequency ablation and fully invasive procedures which include either minimal incision or endoscopic plantar fasciotomy. Although we are trained as surgeons very few cases of plantar fascia and out in the surgery suite: maybe one in 50.

 

What else could it be?

There are several medical conditions that could mimic plantar fasciitis. No matter whom you end up seeing for plantar fasciitis, he or she should be able to distinguish it from tarsal tunnel syndrome, medial calcaneal nerve syndrome, calcaneal bone infection, calcaneal cysts or tumors, Reiter’s syndrome, infracalcaneal bursitis and posterior tibial tendinitis, among other conditions. Again, I think that podiatrists are in the best position to evaluate this list of possible other causes of your heel pain.

 

What to expect at your first visit

A typical heel pain visit starts with a complete lower extremity history and physical examination. The examination should include blood flow and neurological tests as well as it dermatological and biomechanical examination. Ranges of motion of the lower extremity joints and muscle strength should both be part of the examination. Usually to radiographs of each foot are taken at this visit and, in our office at least, the plantar fascia is visualized and its thickness measured with a diagnostic ultrasound machine.

 

Next your doctor should discuss the possible causes of your heel pain which, in medical speak, is called the differential diagnosis. Each diagnosis has some reasons for its inclusion and there are usually tests you can do to evaluate or eliminate each possible cause.

 

Low-Dye strapping

In our office we will usually place a low-Dye strapping on your foot. If you notice, the word “Dye” is capitalizedLow-Dye because it’s named after a podiatrist, Dr. Dye, who first described it in the literature. He had a “high” strapping which was used for ankle sprains and a “low” strapping which is used for plantar fasciitis. This taping method is, sometimes, magical. There have been many cases where people have had heel pain for many months and have seen more than one doctor and did not have any relief from the heel pain until the moment the low-Dye strapping was placed on their foot. A positive response to the low-Dye strapping usually indicates that a biomechanical approach (i.e. orthotics) will probably work. Since the strapping is used to predict the effectiveness of biomechanical therapy, doing a cortisone injection at the first visit when the taping is applied is not advised. With both taping and a cortisone injection at the first visit, the variables are “confounded” and we do not know which one actually worked. Even if I plan to use a cortisone injection as an early therapy I will have the patient come back a day or two after the strapping so I can know if the strapping actually worked.

 

Diagnostic Ultrasound – What is Your Number?

Both our Agoura Hills and Thousand Oaks office have diagnostic ultrasound machines. These are the same ultrasoundUltrasound machines that ob/gyns use to look at babies in the womb. We use them to measure the thickness of the plantar fascia word inserts on the heel bone, the calcaneus. Ultrasound images appear upside down that asked shaped structure going across from left to right on the ultrasound image is the bottom of the heel bone. If you look carefully on the account being photographed see two lines moving from left to right on the bottom of the heel bone. Those two lines are the margins of the plantar fascia. The dotted line you see towards the left in the photograph is actually the measurement of the thickness of the plantar fascia. In this case the plantar fascia is measuring 2.3 mm in thickness. It has been my experience that you can determine the severity of the plantar fasciitis and make some predictions about the eventual treatment of plantar fasciitis by looking and measuring at the plantar fascia with the ultrasound. Here are my general guidelines regarding plantar fascia thickness is determined by the ultrasound:

Thickness                                    Meaning

Less than 4mm thick              Normal thickness

4-6 mm thick                              Moderately thick-mild or early case

6-9mm thick                               Significantly thick – chronic case

Over 9 mm thick                        Severe long standing and probably resistant case

 

Other facts can be determined with the ultrasound image. Often times an area where the plantar fascia has been injured shows up as a large dark circle in the plantar fascia. Infracalcaneal bursitis can also be seen with this modality. If you are looking for a doctor to diagnose and treat your plantar fasciitis, you might want to ask if he or she has a diagnostic ultrasound machine on the premises.

 

X-rays – is there a spur?

X-rays are almost routinely taken during your first visit for plantar fasciitis but, in reality, they’re not as useful as the

Heel Spur ultrasound image. Yes, you may have a heel spur but, as I stated above, the heel spur is not responsible for the pain. The heel spur is just a marker that you have had the plantar fascia pulling hard on the heel bone for a long time. With the radiograph we can look and see if you have evidence of a stress fracture or a cyst in the bone. Stress fractures are actually difficult to see with an x-ray and cysts in the heel bone are exceedingly rare. When we take heel pain x-rays we usually limit ourselves to just two views. Three views, to me, seem like overkill.

 

Mechanical vs. Medical Treatment

Plantar fasciitis can be successfully treated with both medical and chemical methods and a combination of both. Let me explain.

 

Mechanical:

Since plantar fasciitis is an overuse injury of the plantar fascia on the heel bone, we can successfully treat it, in most cases, by lessening the pull of the fascia on heel bone. Proof of this, as I stated above, can be ascertained by the response to a low-Dye strapping. Simply stated, if the taping worked, so will orthotics (in most cases). If the strapping was wildly successful at the first visit we will then make a cast impression of the foot at the second visit to make orthotics. Since it will take 2-3 weeks to get orthotics back we will frequently retake the patient once or twice a week until the orthotics, come in. It can be as simple as that.

Wall stretch to relieve plantar fasciitis painAnother mechanical method is the stretching of both the plantar fascia and the Achilles tendon. Simple wall stretching can be done by the patient two or three times a day. In the illustration the right leg is being stretched. The right knee is locked straight in a heel remains legally on the ground. The left leg, in this case, should the flexed green they have down towards the junction of the wall with the floor. This will cause a dramatic burning pull at the upper calf.

 

 

Towel stretch to relieve plantar fasciitis painA second strategy involves stretching the plantar fascia, itself. In the accompanying illustration a towel is placed around the forefoot and pulled back towards the body while keeping the knee locked. Both of these stretches need to be held for 20 seconds at a time with no bouncing.

More aggressive stretching can be accomplished using a night splints stretches both the Achilles tendon in the plantar fascia for three or more hours at a time, sometimes all night long.

Ice therapy can reduce the inflammation or two or three hours at a time. I find that the easiest method to apply ice toIce and roll stretch to relieve plantar fasciitis pain the heel is to feel a 20 ounce plastic Coke bottle with water and freeze it in the freezer without the cap. Remove the bottle and put the cap back on and roll the midfoot and heel over the depression at the bottom of the Coke bottle. Roll the heel on bottle for 10 min. at a time three times a day. More often is never wrong. You could get in trouble if you apply unclothed skin to ice without motion. The Coke bottle works very well because you roll your heel back and forth on the bottle and never keep the ice in one spot for very long.

 

Physical therapy:

Physical therapy can often do wonders to control the pain of plantar fasciitis. They will use national level of stretching and taping techniques as well as ultrasound treatments and electrical stimulation to bring the pain under control. They have a technique called electrophoresis and phonophoresis where cortisone preparations are painlessly push through the skin using either gentle electric current or the wand of an ultrasound machine. If you visit either of our physical therapist, Amy or Beth, be prepared to go home with a list of exercises and activities to do on your own to control plantar fascial pain.

 

Medical:

Pills: The early stages of plantar fasciitis are inflammatory conditions. As such, anti-inflammatory agents can often make life much more bearable. Oral agents like Motrin, Celebrex, Naprosyn and Voltarin can stop the inflammatory process in its tracks. While over-the-counter Motrin can achieve anti-inflammation levels of medication you need to take 2400mg – 3200 mg per day to do that. At 200mg per tablet that is a whopping 12 to 16 tablets a day in divided doses and taken with meals. Few people feel comfortable taking that many tablets so I write for other medications that need to be taken as infrequently as once or twice a day.

 

Injections:  injections of cortisone mixed with a local anesthetic can often be the Holy Grail of heel pain treatment. I cannot tell you the number of patients who have been permanently and forever cured of their heel pain with a single cortisone injection. This fact combined with the near absence of any injection complications makes it the singular best treatment you can have for plantar fasciitis. I have developed a technique to place the cortisone injection needle in a little pocket between the plantar fascia and the heel bone that, many times, causes no pain whatsoever. Many is the time that patient has asked me after the heel cortisone injection “Doc, have you done it?”  So, if you come to me for a heel spur injection, expect not to even feel it, especially if it’s your left foot. Honestly, I’m better at the left feet.

 

Orthotics

As I stated above, if you had a positive response to the low dye strapping you will probably have a positive response toOrthotics for Plantar Fasciitis functional orthotics. The orthotics that podiatrist make our oftentimes much better than the ones made by physical therapists or chiropractors. It is a little frustrating to have a patient who has an ineffective pair of orthotics from another practitioner say to us that they “already have orthotics” when we can see from the inserts in their shoes they are nothing like the kinds we make. So let me repeat to be perfectly clear, even if you have so-called orthotics from other practitioners, if our low dye strapping make sure foot stop hurting so will our functional orthotics in most cases. This is providing, of course, that you’re able to wear the kinds of shoes in which and orthotic is appropriate. Orthotics cannot be worn in most sandals or flip-flops. They also cannot be worn in most high heels but, as I mentioned above, the mere fact of elevating the heel will probably make your heel stop hurting.

To make orthotics in our office we will take either a fiberglass or a plaster mold of your foot held in what we call the “neutral position” and, and this is important, in a non-weight bearing position. Orthotics made from an outline of your foot or from stepping into foam are not usually considered legitimate orthotics. Once we have your non-weight bearing impression we will send them off to the laboratory along with an order form for one of any number of these signs or styles of orthotic that will hold your foot in this neutral position as you go about your daily activities. Again, I cannot tell you the number of patients who have been, in essence, cured of their plantar fasciitis by wearing a well-made and proper fitting functional orthotics.

 

Do they really work? Ask David P who said, “I had heel pain for a long time and the tape helped right away and gave immediate relief. I got orthotics and broke them in gradually; they worked perfect. I could wear them full-time after four or five days. My arch feels good and I am not having any [heel] pain. I am happy with them.”

 

Or ask Carol S: “Case of Carol S.: Carol was a 52-year-old woman, 5’-5″ and 170 pounds. She worked as a librarian and could wear a variety of shoes to work. Her left heel hurt her for three years before she limped into my office. Prior to her visit with me she received a course of Lodine from her internist and a course of Voltaren from an orthopedic surgeon. In addition the orthopedist gave her a heel cup and three times injected her with cortisone. She continued to have heel pain, especially the first step in the morning. She tried two kinds of arch supports, changing shoes and chondroitin + glucosamine complex from her chiropractor. She saw me on referral from a fellow librarian. An x-ray of her foot revealed a 3-4 mm long heel spur but no other pathology. When I rubbed her foot I could reproduce the pain by touching the spot where the plantar fascia attaches to the foot on the inside of her heel. I made a diagnosis of plantar fasciitis and made my usual recommendations to avoid flat shoes, bare feet, sandals, slippers and socks without shoes. I told her to ice her heels three times a day and then I applied a low-Dye strapping to the left foot. She felt more immediate relief of pain then she did with her cortisone injections. I retaped her twice a week for three weeks. During this time I made a plaster impression of her feet and made a pair of functional orthotics. Wearing the orthotics kept her virtually pain free from that day to now

 

Insurance coverage for orthotics

Functional orthotics works so well that it is a shame that Medicare, and some private insurance plans do not cover them. If you want to know if your insurance plan covers functional orthotics we ask that you call them. The phone number should be on the back of your insurance card. Ask them specifically if they cover functional orthotics and give them the code number L3000 which is the medical code number for functional orthotics. Be sure you write down carefully what they say and who you talk to. Also ask if they need any preauthorization prior to paying for functional orthotics. If orthotics are not covered by your insurance, we have a reasonable cash fee.

For more information about orthotics, including the insurance coverage aspect, please call our office and ask for a copy of our “Orthotic Brochure.”

 

Why do you keep referring to your orthotics as FUNCTIONAL?

From the podiatric point of view orthotics are either functional or accommodative. Accommodative orthotics, often called soft orthotics, are designed just to pad your foot and give it a “cushier” landing. Arch supports, spine levelers and just about anything made of leather or rubber fit into this category. A functional orthotic changes the way your foot functions. It will hold your foot in a pre-designed position. A functional orthotic is made from a plaster or computer impression of your foot, not just measuring the size or having you step into a foam box. Originally accommodative orthotics were made of leather and were designed for patients who needed a more cushioned insole in their shoes. Insurance companies that do cover orthotics require that they be functional to be eligible for coverage.

Who Needs Surgery?

The overwhelming number of cases of plantar fasciitis are brought under control with nonsurgical means. For my patient’s I recommend surgery only if ALL of the following are true:

 

1)      The pain has been present for six months

2)      Two or three cortisone injections have been tried

3)      Orthotics have been tried

4)      Physical therapy or a night split have been tried

 

In our office we offer three types of surgery for resistant plantar fasciitis: 1) shockwave therapy 2) radiofrequency ablation and 3) plantar fasciotomy or cutting the plantar fascia.

 

Shockwave therapy – ESWT.

Sound waves contain energy as anybody who has had their windows rattled by a sonic boom can testify. Shockwave therapy machines gather a very loud shock explosion and concentrated on one tiny little point about 2 inches from the head of the machine. For almost 30 years shockwaves have been used to break apart kidney stones without the need for surgery. For 15 years these little waves have been directed at the insertion site of the plantar fascia on the heel. Unlike what you might expect, attacking a heel spur with sound waves does not break them up. The disappointment at the lack of destruction of the heel spur is offset by the fact this machine has chronic, long-standing plantar fasciitis. The treatment takes about 25 min. and it’s usually done under local anesthesia. After this treatment fully one third of the shockwave patients no longer have any heel pain at all, one third have enough of a reduction that traditional surgery is not needed and one third do not receive much help at all. Surprisingly, there are no known complications from this surgical procedure. Either it helps or it doesn’t but nobody has been made worse. We are one of the only offices in the Southern California area to have a high-energy shockwave therapy machine in our office. We use it for many of the resistant heel cases and it is very effective. The only real complication is financial: many insurances refuse to pay for shockwave therapy. For those of you for whom shockwave therapy is not a covered service we have a very reasonable cash fee structure of $1000 or 1 foot and $1500 if we do both feet. We have another section of our website entirely devoted to shockwave therapy and we ask that you refer to it. http://conejofeet.com/shockwave-therapy

 

A final note on shockwave therapy, do not confuse the high-energy shockwave therapy that we can offer in our office with the low energy shockwave machines that are found in many other podiatry offices and, especially the entire package and physical therapy offices. High-energy shockwave needs some kind of anesthesia, in most cases. Low energy does not. All of the results we are talking about are based upon high-energy shockwave not low energy. You can suspect that your Dr. is dealing with low energy shockwave if he or she offers you a series of four or six treatments for a fixed fee like $400 or $600. High-energy shockwave therapy is, unfortunately, more expensive than this.

 

RFA- Radiofrequency ablation.

There is a new method of performing surgery for plantar fasciitis. This new method was discussed in the June 2011 issue of the Journal of Foot and Ankle Surgery, which is the official publication of the American College of Foot and Ankle Surgeons. The article was written by doctors Hormozi, Lee and Hong who are all residents in the Los Angeles area, one at Tarzana Medical Center any other to add Kaiser Permanente Medical Centers. The method uses radiofrequency ablation. In this method a small needlelike probe is placed through the skin into the plantar fascia at 24 locations in the heel. With each placement of the needle a small electric charge is generated at the tip of the needle which causes a little spark or shock. The 24 total sparks or shocks create a little scarring in the plantar fascia which can result in healing. This is a very exciting alternative for plantar fascia surgery. In our office Dr. Benson and I have use this technique for Achilles tendonitis and it would take only a small modification in the technique to do it for plantar fasciitis. The authors conclude that this technique is an effective and minimally invasive and save surgical option for the treatment of recalcitrant plantar fasciitis and fasciosis in adults. Under anesthesia there are 24 spots where the electrode needle is placed into the skin. This is, of course, done with significant local anesthesia of the area. For the squeamish we could even do this at the surgery center under a little sedation.

 

Plantar Fasciotomy

The most direct and the oldest method for doing surgery on plantar fasciitis is to cut the plantar fascia. 25 years ago, during my residency, the technique involved making a 2-3 inch incision on the medial aspect of the heel and dissecting down to the plantar fascia which was cut the very large and thick scissors. Since the foot was so open and we would always saw the heel spur at the same time. The theory here he was that if a patient did not receive relief from the surgery and saw a heel spur on the x-ray they would point to it and say that is why they still had pain. In reality the heel spur does not need to be removed as I have discussed previously. For this reason there are two lesser dramatic plantar fascial surgery procedures: the minimal incision one that I do and the endoscopic one performed by Dr. Benson and Dr. Payne of my office.

 

Minimal incisional plantar fasciotomy

The technique that I use involves cutting one third of the plantar fascia to a small, 1/4 inch, incision on the bottom of the heel. This can be performed either in the office or at the surgery Center under local anesthesia with or without a little sedation. The incision takes just one little suture stitches to close and the patient can return to regular shoes in three or four days. This has a remarkable success rate in my hands. One of the feared complications of performing a plantar fasciotomy is the possibility of transferring pain to the outside of the foot-the middle of the foot behind the baby toe. I have performed more than 50 of these little surgeries and nobody has ever complained of this outside of the foot pain although it is always a risk and always acknowledged on the consent form.

 

Does plantar fasciotomy really work? Well ask Diane S. from Camarillo wrote to me and said: “I cannot believe how [good] my right foot feels now. After my fall I started to feel the terrible pain in my right heel. This fall was in 1996 and I’ve had to live with this every day until Dr. Zapf operated on it within an office plantar fasciotomy in October 2000. I can now walk without pain in my right foot. This operation consisted of a small incision to the right heel area and I was able to walk within days. I would recommend Dr. Zapf to anyone who needs this kind of foot surgery. I cannot believe it! It’s so great now.”

 

Endoscopic plantar fasciotomy

I feel comparable cutting the plantar fascia through a small incision on the foot. I admit that the cut is “blind” and then I do it by touch and not by sight. I have seen enough plantar fascia surgeries in my career that I am comparable feeling where it is and cutting it blindly. I understand that this does not make most foot surgeons comfortable. Dr. Payne and Dr. Benson prefer cutting the plantar fascia only when they can visualize it. They do this surgery using an endoscope which is a small straw like to which is placed into the heel with a small incision on the inside of the heel. A small, very tiny, camera is placed into the wound and they can actually visualize the plantar fascia as they cut it. This is very elegant. Because this is done at the surgery center under local anesthesia it cannot be done in the office.

 

Who should do the surgery?

There are only two categories of doctors who commonly and routinely perform plantar fasciotomy and heel spur surgeries: podiatrist and orthopedic surgeons. In your area you should use the professional who does the most plantar fascial surgeries and has the most experience. While that could be an orthopedic surgeon in most areas very few orthopedic surgeries do very many foot surgeries. If you are bidding surgeon says he or she does a lot of heel surgeries then you are probably in good hands. More than likely, however, you will be getting surgery from a local podiatrist. And if you do choose the podiatrist, I recommend that you pick one that is Board Certified by the American Board of Podiatric Surgery. You can usually identify these surgeons because they are also Fellows of the American College of Foot and Ankle Surgeons which means they have the initials FACFAS after their name. In our office all three doctors are Fellows of the American College of Foot and Ankle Surgeons

 

Thank you for reading this far. If you have questions that I could answer, feel free to leave them on http://conejofeet.com

 

Michael Zapf, DPM

 

A Beautiful Solution to Ingrown Nails

A Beautiful Solution to Ingrown Nails

 

By: Michael A. Zapf, DPM

 

As filling a cavity is to your dentist, and listening to your lungs is to your family doctor, so is repairing an ingrown nail to your podiatrist. Fixing an ingrown nail is one of the first things we learn in podiatric medical school. Every podiatrist graduates with the certain knowledge that they know how to fix an ingrown nail both temporarily and permanently. What separates one podiatrist from another is the art of dealing with the fears of the patient, and aesthetics of the ingrown nail repair. In our office, the doctors of the Agoura-Los Robles Podiatry Centers have performed many thousands of ingrown nail repairs, and we have come to appreciate the subtleties and the aesthetics of the procedure.

 

I remember the first ingrown nail I repaired in podiatric medical school some 25 years ago. I worried about it for two days. I saw the patient on our Thursday afternoon clinic during my junior year in school. The young lady whose toe I was about to anesthetize would be the second toe I had ever made numb; the first was on a classmate the day prior (which answers the frequent question about how we ever learned to give injections). I reflect, with honor and awe, the courage all of the patients the medical school had come in and let us use them for our practice. I digress. The whole procedure that day took about two hours. Little did I know that in the future I would have to do this whole procedure in less than 30 minutes. A few years later I would be teaching this technique to junior students. I have seen more than one case where the entire three-hour afternoon clinic was devoted to the repair of just one ingrown nail. Ah, those were the days.

 

The name “ingrown nail” is a bit of a misnomer. Yes, it is where the ingrown nail pushes into the side of the toe creating redness, inflammation and pain. But more often than not it is the sock and shoe which push the tissues of the toe into the otherwise benign nail. It can occur in two varieties: acute and chronic.

 

Acute ingrown nails tend to occur in the younger population with a heavy predominance in the teenage years. These ingrown nails tend to be very swollen, red, draining and ridiculously painful. By the time we see these patients they have tried soaking the foot, using topical antibiotics and, in many cases, a course of oral antibiotics provided by their pediatrician or family doctor. These younger patients, even the huge high school football players, are often very afraid to tell their parents of their plight. They are afraid they will end up in an office like mine with a need to remove the edge of the ingrown nail. They have a sense that this will require an injection of anesthesia, which is usually the case. Fear of an injection keeps them from telling their parents of the ingrown nail until infection, severe pain or the site of a bloody sock arouses suspicion in mom or dad. These young people present to our office in as much apprehension as pain. It is in patients like these that we prove our worth. All three of us are gentle and specialize in cowards.

The first step in preparing an ingrown nail of this sort will require the toe to be put to sleep with local anesthetic. Each of the three doctors in our office have slightly different techniques to accomplish this with the least amount of pain. We are all parents of teenagers, or near teenagers, and are very sensitive to the fears they have about the visit to the podiatry office. In my case I use the smallest needle and smallest syringe possible and anesthetize the toe with less than 1 mL of plain Xylocaine. Before I inject, I use a topical refrigerant anesthetic and, for the more timid patients, I have purchased a vibration device that blocks most of the pain of the injection. In my 25 years of practice I have had only three patients who would not let me inject their toe. For these patients we have resorted to using a surgery center and gentle, quick acting inhalation anesthesia. All of the other hundreds, perhaps thousands, of patients have allowed me to inject their nail and have always been surprised at how little pain my injection produced.

 

Adult ingrown nails are somewhat different. Usually the ingrown nail of an adult patient is not swollen and draining but is, instead, mildly inflamed and chronically painful with any pressure on the outside of the toe. While most adults are not nearly as afraid of the injection as the teenagers, I still use all of the techniques that I use to make the injection painless for the children on the adults. I figure, why should the kids have all the fun?

 

Once the toe is numb we have a decision to make. Should we perform a simple procedure where the edge of the toenail is trimmed to get the patient out of the immediate pain? Or should we perform a more permanent procedure so that the ingrown nail will never return? This is a question all podiatrists face every time a patient within ingrown nail comes to the office. The simple answer is, if the ingrown nail is expected to return then a permanent correction is advised. Every podiatrist has a little different view on this so you will expect to have a discussion with your podiatrist about the best method for you. In my perspective an ingrown nail that has occurred for just the first time probably needs just a temporary removal of the edge of the nail. Recurrent and chronic ingrown nails usually require permanent correction. I do bias this a little bit with my younger patients who are terrified of the anesthesia process. My reasoning here is that we only want to anesthetize the toe one time. If the child or the teenager allows me to get the toe numb, then I am going to fix it permanently so they are not faced with this dilemma ever again.

 

Once the toe is anesthetized we use some rather delicate instruments to remove a very thin edge of the nail plate. You will be happy to know that all three doctors in our office are very conservative in the amount of the nail that is removed. We have seen patients that have had so much nail removed that the remaining nail looks offensive to the patient. Sometimes the nail is so thin it resembles a claw. We never want this to happen in our office. All three of us figure that it would be better to go back at a later date and remove a little more nail then to have the patient feel we removed too much nail the first time. My analogy that I use with my patient’s is going to the hairdresser before an important occasion. The last thing you want is to be aghast that too much hair was cut. It would be much better for the hairdresser to remove not enough hair and have you asked them to remove more than to have you feel the special occasion was ruined by removing too much hair the first time. I can’t emphasize this point enough. For the many years I taught this procedure at the LAC/USC Medical Center, I continually begged and pleaded with my students not to remove too much nail. More can always be removed.

Ingrown Nail and Matricectomy in Thousand Oaks and Agoura Hills

Once the edge of the nail is removed a decision needs to be made about whether the nail removal should be temporary or permanent. If the nail border removal is temporary then the toe is dressed with a dressing at this point. If the nail border removal is going to be permanent then a chemical is used to kill the nail root responsible for growing the thin edge of the nail. Done correctly you will never even noticed that any nail border was removed. The accompanying photograph is of a young woman who returned to the office 10 days after a permanent nail removal procedure was performed. I cannot imagine that anyone would be embarrassed to show this nail to anyone. It looks perfectly natural and normal. This is the result that all the doctors in our office try to achieve every time we perform a permanent nail procedure.

 

 

It may be beneficial to read the written testimonial this young lady gave about her nail procedure.

 

After two years of pain due to an ingrown toenail and unsuccessful treatment by a different Dr. I was excited to read about doctors asked technique in the local newspaper. The procedure took only a few minutes and I had only minimal pain that night. I was nervous to remove the bandage the next day, but was pleasantly surprised that I could hardly even tell he had removed the edge of the nail. Within two days I was back to walking the dog and wearing sneakers. Just a couple of days later I was running and just yesterday playing tennis without pain. Nine days later, my toe looks great and feels great. I only wish I had known about this two years ago. Much thanks to Dr. Zapf.”

-Alicia S

 

If you have an ingrown nail please feel free to make an appointment with Dr. Benson, Dr. Payne or with myself. We all are trained in the treatment of ingrown nails using both the temporary and the permanent procedure. We do it with a minimal amount of pain and specialize in doing the procedure on children. Our goal when doing a permanent procedure is to make it look like the one in the photograph accompanying this story.

 

If you would like to tell us about your ingrown nail experience, either in our office or from another doctor, please let us know by sending us an e-mail at admin@conejofeet.com

 

If you have any questions about your ingrown nails we will be also more than happy to answer them on our website, http://conejofeet.com

Hyperpronation and Children

Hyperpronation and Children
By Michael A. Zapf DPM, MPH, FACFAS

 

Pronation is the flattening of the foot that occurs in every walking cycle when the foot lands on the ground and becomes flexible to adapt to changes in terrain. It is the natural part of the flattening (pronation) and unflattening (supination) cycles our feet go through with every step. Some people, children included, pronated too much. “Too much” are difficult words to quantify but, like ±the Supreme Court judges said about another subject, you’ll know it when you see it. I use a 1 to 10 scale and I think too much pronation is at the 8-10 levels. Children who are extra-flexible (double jointed) pronate worse than those who do not. They pronate to the end of the range of motion of the joints and beyond.

Does pronation always need treatment?

Certainly, if your child’s pronation results in a painful foot, treatment is necessary. But what do you do if your child pronates excessively but does not have pain or other symptoms? For these children I use a pragmatic approach. Children who pronate a 1-3 on a 10 point scale just need to wear stable shoes such as an athletic shoe. Skateboarding shoes, sandals and thongs usually do not provide enough foot support. I rarely make orthotics for these children. Children who pronate between a 4-7 on a 10 point scale can certainly benefit from functional prescription orthotics, especially if they have foot fatigue, leg pain or difficulty with extended athletic activities. I believe children who pronate at a level of 8 or higher deserve functional prescription orthotics and they should be made a priority. Hyperpronated children give way to hyperpronated adults and all the problems that such a foot is heir to with plantar fasciitis, bunions, hammertoes, arch pain and many more maladies.

Hyperpronation in Thousand Oaks and Agoura HillsThree degrees of pronation. I would grade the foot on the far left as a “3″ on a 10-point pronation scale, the one in the middle as a “9″ and the feet on the right as a “10.”

What are orthotics?

Functional orthotics that are used by podiatrists are thermal plastic support devices that are placed in the shoe and hold the foot at a predetermined position. That predetermined position is one where we feel your child’s foot would best function. We take a fiberglass or plaster impression of the foot while holding it in the correct position. The molds are sent to any one of several laboratories where devices will be made to our specific prescription. Please see our orthotic brochure for more complete information. To determine if your insurance will pay for some or all of your orthotics we ask you to call down and give them the following billing codes:

 

29799 casting procedure for orthotics
A4590 fiberglass casting sock, if used
L3000-LT left orthotic device
L3000-RT right orthotic device

 

Our office accepts the fee approved by your insurance company. We also have a cash discount price in case there is no insurance coverage. Details of this program are in our orthotic brochure.

Richie Brace

When an in-shoe orthotic does not supply enough support, we can make an orthotic with two plastic stirrups that attached to both sides of the ankle. The stirrups are hinged so that the ankle joint can have successful up and down motion but still providing extreme support against pronation. This device is often called a Richie brace. Some children pronate so much that they need to wear a Richie brace full-time and others just need to wear it when playing soccer, basketball or other aggressive side to side sports. For Richie braces we use the insurance code L1970. Your insurance carrier can tell you what part of that for which you might be responsible.

If it still hurts, think “arthroereisis” or a tiny internal orthotic for the foot

Orthotics are great but they are not miracle workers. Children who pronate excessively often pronate too much for anInternal Orthotic Thousand Oaks and Agoura Hills orthotic to work effectively. In other cases orthotics work just fine but the child participates in ballet, gymnastics, martial arts or other activities where they cannot wear orthotic containing shoes. In these circumstances we can use a jellybeans sized “internal orthotic” that is slipped into the lateral side of the foot that stops the pronation cold. This procedure is called subtalar arthroeresis and takes about 20 to 30 minutes per foot under general anesthesia. While we give children a removable walking cast where after surgery they often surprise us by walking comfortably on their feet the day after surgery. The arthroeresis implant, itself, costs about $1000 each and the fee for putting it into the foot, which has an “unlisted” code of 99097, is about $1200. The two greatest charms of the internal arthroeresis implant is the ease of putting it into the foot and the similar ease of removing it if that is ever needed. Removing a subtalar joint arthroeresis implant is a very infrequent event.

The Role of Tight Gastrocs

During your child examination in our office we will do a maneuver to assess the tightness of your child’s Achilles tendon, specifically the portion of the Achilles made up from the tendon fibers that derive from the gastrocnemius muscle. A tight gastroc it is a major source of pronation. If the gastrocnemius muscle is tight it could be both a cause of pronation and a source of foot pain with orthotics. Simple treatments for a tight gastrocnemius tendon including the use of heel lifts, heels on shoes and stretching techniques. If pronation is painful and surgery is ever contemplated then the role of a tight gastrocnemius tendon must be assessed. There are occasions when the gastrocnemius portion of the Achilles tendon needs to be surgically stretched or lengthened in a procedure called a gastrocnemius recession. We do this procedure with an endoscope using a small half-inch incision. The postoperative care for a gastrocnemius recession would include the use of a removable walking cast or a splint for 2 to 3 weeks after the surgery. Since crutches are sometimes necessary, we much prefer doing only one foot at a time. The surgery results in a very small loss of strength from the tendon which can usually be overcome with strengthening exercises and physical therapy. A small weakening of the muscle is the trade-off for eliminating a dramatic force of pronation that is producing pain and debility in your child. Note, the gastrocnemius recession code is 27687 and the fee for this is $1150. Despite any fees we charge, we accept the fee approved by your insurance company and a call to them can tell you what this figure is for your insurance.

Extra bones on the inside of the foot

A small number of unlucky children have an extra bone (technically it is called an accessory navicular bone) on the inside of the foot below the inside ankle bone. Most of the time this extra bone does not get in anyone’s way and can be safely left alone. Sometimes, however, this little bone hurts out of proportion to its size. It hurts either because the bone wedges against the side of the shoe or because the posterior tibial tendon, which normally inserts on the bottom of the foot, inserts, instead, on the accessory bone. The first treatment for a painful accessory bone would be to make an orthotic special accommodation made for the extra bone. In most cases this will allow them to wear their regular shoes and do their regular activities without pain. If the little bone hurts too much, it needs to be removed. The removal of this bone is done under a light general anesthesia and takes about 45 minutes. The posterior tibial tendon that is attached to this bone is usually tucked under the foot and attached with a little anchor. Postoperatively we asked these children to be in a removable walking cast for three weeks and crutches are sometimes needed. If children pronated excessively, this procedure, alone, will not stop their pronation. If painful pronation is part of the symptom complex the usual treatment would be the removal of the accessory navicular, reefing up the posterior tibial tendon, the subtalar arthroeresis implant and, if necessary, lengthening the gastrocnemius portion of the Achilles tendon.

Summary:

Children who have normal arched or slightly pronated feet and who do not have symptoms of pain or disability probably do not require orthotics. Children who pronate moderately and do not have significant pain do not “require” orthotics but probably it’s not bad to have them. Children who pronate excessively, in the 8 to 10 range on a 10 point scale, probably should be treated with orthotics, at least. Symptomatic children need the amount of support and treatment that it takes for them not to be symptomatic. It should never hurt to be a kid. If an orthotic is all that it takes, that we can stop there. Pain, despite orthotics, demands the use of a Richie brace or even surgery. The most common surgery for hyperpronation is the use of a subtalar arthroeresis implant which is a minimally traumatic surgery performed with a half-inch incision. It does require a light general anesthesia, however. If tight gastrocnemius tendons are found in need to be addressed. If heel lifts or heeled shoes cannot solve the tight gastrocnemius problem by themselves then a gastrocnemius recession, also done with a half-inch incision, should be entertained. Many more complex flat foot surgeries are available for more special cases as you will see as you “Google” the following words:

Pediatric flat foot, Pronation and hyperpronation, Arthroereisis, Subtalar implant, Gastrocnemius recession, Accessory navicular, Functional foot orthotics, Custom foot orthotics